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Purpose: We are doing this survey to get information from students so we can possibly

start a couple of counseling groups. We want to create groups where students can join
and talk about their problems with students that might be dealing with the same issues
you are dealing with. The information you write on this survey is information that will be
read by Mount View Counselors only.

Teachers:________________________ Date:_______________
Student:_____________________________
Instructions
Please put your teachers name, class, date and your name in the spaces
above. Read each question carefully and CIRCLE the best answer you think
matches your situation.
Family Issues Survey
1) Who is your MOST favorite MUSIC celebrity living today?
Rihanna
Coldplay
Other:____________________

Jennifer Lopez

2) Does school start too early or too late?


______________________________________________________________________________
3) Does your family live with another family in a different part of an apartment,
house or room?

Yes

NO

If so, why do you think this is?


_____________________________________________________________________________
_____________________________________________________________________________

4) Do you feel worried or scared that you or a family member will be separated?
Always
not know

Sometimes

Never

I do

If so, in what way would that happen?


_____________________________________________________________________________

Purpose: We are doing this survey to get information from students so we can possibly
start a couple of counseling groups. We want to create groups where students can join
and talk about their problems with students that might be dealing with the same issues
you are dealing with. The information you write on this survey is information that will be
read by Mount View Counselors only.
_____________________________________________________________________________

5) Is someone you care about in jail or prison?

Always
Sometimes
If so,
how do you feel about
them being in there?
not know

Never

I do

If so, who are they and what do they mean to you?


_____________________________________________________________________________
_____________________________________________________________________________

6) Are your parents separated, going to separate, or divorced?


Yes

No

If so, how has your parents separation or divorce made you feel?
______________________________________________________________________________
______________________________________________________________________________

7) Has someone close to you died (passed away) or may be passing soon?
Yes
No
If so, who are they and how long has it been since they have passed?
_____________________________________________________________________________
_____________________________________________________________________________

8) Is deportation a problem you or your family fear?


Yes
No
How come?

Purpose: We are doing this survey to get information from students so we can possibly
start a couple of counseling groups. We want to create groups where students can join
and talk about their problems with students that might be dealing with the same issues
you are dealing with. The information you write on this survey is information that will be
read by Mount View Counselors only.
____________________________________________________________________________

____________________________________________________________________________